Preferred Drug List Illinois Medicaid€¦ · · 2018-03-20ipratropium bromide/albuterol sulfate...

Preferred Drug List

Illinois Medicaid4/1/2018

*Exceptions as Noted Below* ADHD Agents: Prior authorization required for participants under 6 years of age and participants 19

years of age and older

Spiriva AER 1.25mcg: Prior authorization NOT required for participants ages 6-17 years

Budesonide: Prior authorization NOT required for participants age 7 years and under

Anticonvulsants: Prior authorization NOT required for non-preferred epilepsy agents for those participants with a diagnosis of epilepsy or seizure disorder in Department records

Antipsychotics: Prior authorization required for participants under 8 years of age and long-term care residents

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Category Preferred Preferred, Requires PA Non-PreferredADHD Agent - Amphetamine Mixtures* ADDERALL XR ADDERALL

AMPHET/DEXTR TAB 10MG AMPHET/DEXTR CAP 10MG ER

AMPHET/DEXTR TAB 12.5MG AMPHET/DEXTR CAP 15MG ER





AMPHET/DEXTR TAB 7.5MG MYDAYIS

ADHD Agent - Amphetamines* VYVANSE ADZENYS ER

ADZENYS XR-ODT

DESOXYN

DEXEDRINE

DEXTROAMPHETAMINE SULFATE

DEXTROAMPHETAMINE SULFATE ER

DYANAVEL XR

EVEKEO

METHAMPHETAMINE HCL

PROCENTRA

ZENZEDI

ADHD Agent - Selective Alpha Adrenergic Agonists* CLONIDINE HCL ER

CLONIDINE HYDROCHLORIDE ER

CLONIDINE HYDROCLORIDE

GUANFACINE ER

INTUNIV

KAPVAY

ADHD Agent - Selective Norepinephrine Reuptake

Inhibitor*

ATOMOXETINE

STRATTERA

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Preferred Drug List

Illinois Medicaid

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Category Preferred Preferred, Requires PA Non-Preferred

4/1/2018

Preferred Drug List

Illinois Medicaid

ADHD Agent - Stimulants - Misc.* CONCERTA APTENSIO XR

DEXMETHYLPHENIDATE HCL ARMODAFINIL

DEXMETHYLPHENIDATE HYDROCHLORIDE COTEMPLA XR-ODT

FOCALIN XR DAYTRANA

METADATE ER DEXMETHYLPHENIDATE HCL ER

METHYLPHENID TAB 10MG FOCALIN

METHYLPHENID TAB 10MG ER METHLPHENIDA CHW 2.5MG

METHYLPHENID TAB 20MG METHYLIN

METHYLPHENID TAB 20MG ER METHYLPHENID CAP 10MG

METHYLPHENID TAB 5MG METHYLPHENID CAP 20MG

METHYLPHENID CAP 20MG ER

METHYLPHENID CAP 30MG






METHYLPHENID CHW 10MG

METHYLPHENID CHW 5MG

METHYLPHENID TAB 18MG ER





METHYLPHENIDATE HCL CD

METHYLPHENIDATE HCL ER (LA)

METHYLPHENIDATE HYDROCHLORIDE

METHYLPHENIDATE HYDROCLORIDE ER

MODAFINIL

NUVIGIL

PROVIGIL

QUILLICHEW ER

QUILLIVANT XR

RITALIN

RITALIN LA

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Illinois Medicaid

Alcohol Deterrents ACAMPROSATE CALCIUM DR

ANTABUSE

DISULFIRAM

Aminoglycosides - Inhaled KITABIS PAK BETHKIS

TOBI

TOBI PODHALER

TOBRAMYCIN

Analgesics - Anti-Inflammatory - Anti-TNF-alpha -

Monoclonal Antibodies

HUMIRA SIMPONI

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK SIMPONI ARIA

HUMIRA PEN

HUMIRA PEN-CROHNS DISEASESTARTER

HUMIRA PEN-PSORIASIS STARTER

Analgesics - Anti-Inflammatory - Antirheumatic - Janus

Kinase (JAK) Inhibitors

XELJANZ

XELJANZ XR

Analgesics - Anti-Inflammatory - Interleukin-1 Receptor

Antagonist (IL-1Ra)

KINERET

Analgesics - Anti-Inflammatory - Interleukin-6 Receptor

Inhibitors

ACTEMRA

KEVZARA

Analgesics - Anti-Inflammatory - Phosphodiesterase 4

(PDE4) Inhibitors

OTEZLA

Analgesics - Anti-Inflammatory - Selective Costimulation

Modulators

ORENCIA

ORENCIA CLICKJECT

Analgesics - Anti-Inflammatory - Soluble Tumor Necrosis

Factor Receptor Agents

ENBREL

ENBREL MINI

ENBREL SURECLICK

Analgesics - Opioid - Codeine Combinations ACETAMINOPHEN/CODEINE BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE

ACETAMINOPHEN/CODEINE PHOSPHATE FIORINAL/CODEINE #3

ASCOMP/CODEINE TYLENOL/CODEINE #3

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE TYLENOL/CODEINE #4

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Illinois Medicaid

Analgesics - Opioid - Dihydrocodeine Combinations ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE BITARTRATE

PANLOR

Analgesics - Opioid - Hydrocodone Combinations HYDROCO/APAP SOL 7.5-325 HYDROCO/APAP TAB 10-300MG

HYDROCO/APAP TAB 10-325MG HYDROCO/APAP TAB 2.5-325

HYDROCO/APAP TAB 7.5-325 HYDROCO/APAP TAB 5-300MG

HYDROCOD/IBU TAB 7.5-200 HYDROCO/APAP TAB 7.5-300

HYDROCODONE/ACETAMINOPHEN HYDROCOD/IBU TAB 10-200MG

LORCET HYDROCOD/IBU TAB 5-200MG

LORCET HD IBUDONE

LORCET PLUS LORTAB

NORCO

VERDROCET

VICODIN

VICODIN ES

VICODIN HP

Analgesics - Opioid - Tramadol Combinations TRAMADOL HYDROCHLORIDE/ACETAMINOPHEN

ULTRACET

Analgesics - Opioid Agonists CODEINE SULFATE EMBEDA ABSTRAL

HYDROMORPHONE HCL MORPHINE SUL TAB 100MG ER ACTIQ

MEPERIDINE HCL MORPHINE SUL TAB 15MG ER ARYMO ER

MORPHINE SULFATE MORPHINE SUL TAB 200MG ER CONZIP

OXYCODONE HCL MORPHINE SUL TAB 30MG ER DEMEROL

OXYCODONE HYDROCHLORIDE MORPHINE SUL TAB 60MG ER DILAUDID

TRAMADOL HCL DOLOPHINE

DURAGESIC

EXALGO

FENTANYL

FENTANYL CITRATE ORAL TRANSMUCOSAL

FENTORA

HYDROMORPHONE HCL ER

HYDROMORPHONE HYDROCHLORIDE

HYDROMORPHONE HYDROCHLORIDE ER

HYSINGLA ER

KADIAN

LAZANDA

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LEVORPHANOL TARTRATE

METHADONE HCL

METHADONE HCL INTENSOL

METHADOSE

METHADOSE SUGAR-FREE

MORPHABOND ER

MORPHINE SUL CAP 100MG ER











MS CONTIN

NUCYNTA

NUCYNTA ER

OPANA

OPANA ER (CRUSH RESISTANT)

OXAYDO

OXYCODONE HCL ER

OXYCONTIN

OXYMORPHONE HYDROCHLORIDE

OXYMORPHONE HYDROCHLORIDE ER

ROXICODONE

SUBSYS

TRAMADOL HCL ER

ULTRAM

XTAMPZA ER

ZOHYDRO ER

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Illinois Medicaid

Analgesics - Opioid Combinations ENDOCET OXYCODONE/ASPIRIN

OXYCODONE/ACETAMINOPHEN OXYCODONE/IBUPROFEN

PERCOCET

PRIMLEV

Analgesics - Opioid Partial Agonists BUNAVAIL BELBUCA

BUPRENORPHINE HCL BUPRENORPHINE

BUPRENORPHINE HCL/NALOXONE HCL BUTORPHANOL TARTRATE

PROBUPHINE IMPLANT KIT BUTRANS

SUBLOCADE PENTAZOCINE/NALOXONE HCL

SUBOXONE

ZUBSOLV

Antiasthmatic And Bronchodilator Agents - Adrenergic

Combinations

ADVAIR DISKUS ADVAIR HFA

BEVESPI AEROSPHERE AIRDUO RESPICLICK 113/14

DULERA AIRDUO RESPICLICK 232/14

IPRATROPIUM BROMIDE/ALBUTEROL SULFATE AIRDUO RESPICLICK 55/14

SYMBICORT ANORO ELLIPTA

BREO ELLIPTA

COMBIVENT RESPIMAT

FLUTICASONE PROPIONATE/SALMETEROL

STIOLTO RESPIMAT

TRELEGY ELLIPTA

UTIBRON NEOHALER

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Antiasthmatic And Bronchodilator Agents - Beta

Adrenergics

ALBUTEROL NEB 0.083% ALBUTEROL

ALBUTEROL NEB 0.5% ALBUTEROL TAB 2MG

ALBUTEROL NEB 0.63MG/3 ALBUTEROL TAB 4MG

ALBUTEROL NEB 1.25MG/3 ALBUTEROL SULFATE ER

ALBUTEROL SYP 2MG/5ML ARCAPTA NEOHALER

PROAIR HFA BROVANA

PROVENTIL HFA LEVALBUTEROL

SEREVENT DISKUS LEVALBUTEROL HCL

TERBUTALINE SULFATE LEVALBUTEROL HYDROCHLORIDE

LEVALBUTEROL TARTRATE HFA

METAPROTERENOL SULFATE

PERFOROMIST

PROAIR RESPICLICK

STRIVERDI RESPIMAT

VENTOLIN HFA

XOPENEX

XOPENEX CONCENTRATE

XOPENEX HFA

Antiasthmatic And Bronchodilator Agents -

Bronchodilators - Anticholinergics*

ATROVENT HFA INCRUSE ELLIPTA

IPRATROPIUM BROMIDE LONHALA MAGNAIR REFILL KIT

SPIRIVA AER 1.25MCG LONHALA MAGNAIR STARTER KIT

SPIRIVA HANDIHALER SEEBRI NEOHALER

SPIRIVA SPR 2.5MCG

TUDORZA PRESSAIR

Antiasthmatic And Bronchodilator Agents - Leukotriene

Modulators

ZILEUTON ER

ZYFLO

ZYFLO CR

Antiasthmatic And Bronchodilator Agents - Leukotriene

Receptor Antagonists

MONTELUKAST SODIUM ACCOLATE

ZAFIRLUKAST SINGULAIR

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Illinois Medicaid

Antiasthmatic And Bronchodilator Agents - Steroid

Inhalants*

ASMANEX TWISTHALER 120 METERED DOSES AEROSPAN

ASMANEX TWISTHALER 14 METERED DOSES ALVESCO

ASMANEX TWISTHALER 30 METERED DOSES ARMONAIR RESPICLICK 113



BUDESONIDE ARNUITY ELLIPTA

FLOVENT DISKUS ASMANEX HFA

FLOVENT HFA PULMICORT

QVAR PULMICORT FLEXHALER

QVAR REDIHALER

Anticoagulants - Direct Factor Xa Inhibitors ELIQUIS SAVAYSA

ELIQUIS STARTER PACK

XARELTO

XARELTO STARTER PACK

Anticoagulants - Low Molecular Weight Heparins ENOXAPARIN SODIUM LOVENOX

FRAGMIN

Anticoagulants - Synthetic Heparinoid-Like Agents FONDAPARINUX SODIUM ARIXTRA

Anticoagulants - Thrombin Inhibitors - Selective Direct &

Reversible

PRADAXA

Anticonvulsants - AMPA Glutamate Receptor

Antagonists*

FYCOMPA

Anticonvulsants - Benzodiazepines* CLONAZEPAM CLONAZEPAM ODT

DIASTAT ACUDIAL KLONOPIN

DIASTAT PEDIATRIC ONFI

DIAZEPAM RECTAL GEL

Anticonvulsants - Carbamates* FELBAMATE

FELBATOL

Anticonvulsants - GABA Modulators* GABITRIL

SABRIL

TIAGABINE HYDROCHLORIDE

VIGABATRIN

Anticonvulsants - Hydantoins* DILANTIN CAP 30MG DILANTIN CAP 100MG

PHENYTOIN DILANTIN INFATABS

PHENYTOIN INFATABS DILANTIN-125

PHENYTOIN SODIUM EXTENDED PEGANONE

PHENYTEK

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Anticonvulsants - Misc.* CARBAMAZEPIN TAB 100MGER APTIOM

CARBAMAZEPIN TAB 200MG ER BANZEL

CARBAMAZEPIN TAB 400MG ER BRIVIACT

CARBAMAZEPINE CARBAMAZEPIN CAP 100MG ER

EPITOL CARBAMAZEPIN CAP 200MG ER

GABAPENTIN CARBAMAZEPIN CAP 300MG ER

LAMOTRIGINE CARBATROL

LEVETIRACETAM KEPPRA

LEVETIRACETAM ER KEPPRA XR

LYRICA LAMICTAL

OXCARBAZEPINE LAMICTAL CHEWABLE DISPERSIBLE

PRIMIDONE LAMICTAL ODT

ROWEEPRA LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE

ROWEEPRA XR LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

TOPIRAMATE LAMICTAL STARTER/TAKING VALPROATE

ZONISAMIDE LAMICTAL XR

LAMOTRIGINE ER

LAMOTRIGINE ODT

LAMOTRIGINE STARTER KIT/BLUE

LAMOTRIGINE STARTER KIT/GREEN

LAMOTRIGINE STARTER KIT/ORANGE

LAMOTRIGINE TITRATION

MYSOLINE

NEURONTIN

OXTELLAR XR

QUDEXY XR

SPRITAM

TEGRETOL

TEGRETOL-XR

TOPAMAX

TOPAMAX SPRINKLE

TOPIRAMATE ER

TRILEPTAL

TROKENDI XR

VIMPAT

ZONEGRAN

Prior authorization is NOT required for non-preferred

epilepsy agents for those participants with a diagnosis

of epilepsy or seizure disorder in Department records.

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Illinois Medicaid

Anticonvulsants - Succinimides* ETHOSUXIMIDE CELONTIN

ZARONTIN

Anticonvulsants - Valproic Acid* DIVALPROEX SODIUM DEPAKENE

DIVALPROEX SODIUM DR DEPAKOTE

DIVALPROEX SODIUM ER DEPAKOTE ER

VALPROIC ACID DEPAKOTE SPRINKLES

Antidepressants - Alpha-2 Receptor Antagonists

(Tetracyclics)

MIRTAZAPINE REMERON

MIRTAZAPINE ODT REMERON SOLTAB

Antidepressants - Misc. BUPROPION HCL APLENZIN

BUPROPION HCL ER FORFIVO XL

BUPROPION HCL SR WELLBUTRIN SR

BUPROPION HCL XL WELLBUTRIN XL

BUPROPION HYDROCHLORIDE

MAPROTILINE HCL

Antidepressants - Selective Serotonin Reuptake

Inhibitors (SSRIs)

CITALOPRAM CELEXA

CITALOPRAM HYDROBROMIDE FLUOXETINE

ESCITALOPRAM OXALATE FLUOXETINE TAB 10MG

FLUOXETINE CAP 10MG FLUOXETINE TAB 20MG

FLUOXETINE CAP 20MG FLUOXETINE TAB 60MG

FLUOXETINE CAP 40MG FLUOXETINE DR

FLUOXETINE SOL 20MG/5ML FLUOXETINE HYDROCHLORIDE

FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE ER

PAROXETINE HCL LEXAPRO

SERTRALINE HCL PAROXETINE HCL ER

PAXIL

PAXIL CR

PEXEVA

PROZAC

ZOLOFT

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Illinois Medicaid

Antidepressants - Serotonin Modulators TRAZODONE TAB 100MG NEFAZODONE HCL

TRAZODONE TAB 150MG TRAZODONE TAB 300MG

TRAZODONE TAB 50MG TRINTELLIX

TRAZODONE HYDROCHORIDE VIIBRYD

VIIBRYD STARTER PACK

Antidepressants - Serotonin-Norepinephrine Reuptake

Inhibitors (SNRIs)

DULOXETINE CAP 20MG CYMBALTA

DULOXETINE CAP 30MG DESVENLAFAXINE ER

DULOXETINE CAP 60MG DULOXETINE CAP 40MG

VENLAFAXINE CAP 150MG ER EFFEXOR XR

VENLAFAXINE CAP 37.5 ER FETZIMA

VENLAFAXINE CAP 75MG ER FETZIMA TITRATION PACK

VENLAFAXINE HCL KHEDEZLA

PRISTIQ

VENLAFAXINE TAB 150MG ER


VENLAFAXINE TAB 37.5 ER


Antidiabetic - Amylin Analogs SYMLINPEN 120

SYMLINPEN 60

Antidiabetics - Alpha-Glucosidase Inhibitors ACARBOSE GLYSET

MIGLITOL PRECOSE

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Antidiabetics - Biguanides METFORMIN TAB 500MG ER FORTAMET

METFORMIN TAB 750MG ER GLUCOPHAGE

METFORMIN HCL GLUCOPHAGE XR

METFORMIN HYDROCHLORIDE GLUMETZA

METFORMIN TAB 1000 ER

METFORMIN TAB 500MG ER

METFORMIN ER TAB 1000MG

METFORMIN HYDROCHLORIDE ER

RIOMET

Antidiabetics - Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA ALOGLIPTIN

TRADJENTA NESINA

ONGLYZA

Antidiabetics - Dipeptidyl Peptidase-4 Inhibitor-

Biguanide Combinations

ALOGLIPTIN/METFORMIN HCL

JANUMET

JANUMET XR

JENTADUETO

JENTADUETO XR

KAZANO

KOMBIGLYZE XR

Antidiabetics - Dopamine Receptor Agonists - Ergot

Derivatives

CYCLOSET

Antidiabetics - DPP-4 Inhibitor-Thiazolidinedione

Combinations

ALOGLIPTIN/PIOGLITAZONE

OSENI

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Illinois Medicaid

Antidiabetics - Human Insulin HUMALOG ADMELOG

HUMALOG JUNIOR KWIKPEN ADMELOG SOLOSTAR

HUMALOG KWIKPEN AFREZZA

HUMALOG MIX 50/50 APIDRA

HUMALOG MIX 50/50 KWIKPEN APIDRA SOLOSTAR

HUMALOG MIX 75/25 BASAGLAR KWIKPEN

HUMALOG MIX 75/25 KWIKPEN FIASP

HUMULIN 70/30 FIASP FLEXTOUCH

HUMULIN 70/30 KWIKPEN NOVOLIN 70/30

HUMULIN N NOVOLIN 70/30 RELION

HUMULIN N KWIKPEN NOVOLIN N

HUMULIN R NOVOLIN N RELION

HUMULIN R U-500 (CONCENTRATED) NOVOLIN R

HUMULIN R U-500 KWIKPEN NOVOLIN R RELION

LANTUS NOVOLOG

LANTUS SOLOSTAR NOVOLOG FLEXPEN

LEVEMIR NOVOLOG MIX 70/30

LEVEMIR FLEXTOUCH NOVOLOG MIX 70/30 PREFILLED FLEXPEN

NOVOLOG PENFILL

TOUJEO SOLOSTAR

TRESIBA FLEXTOUCH

Antidiabetics - Incretin Mimetic Agents (GLP-1 Receptor

Agonists)

BYETTA ADLYXIN

VICTOZA ADLYXIN STARTER PACK

BYDUREON

BYDUREON BCISE

BYDUREON PEN

OZEMPIC

TANZEUM

TRULICITY

Antidiabetics - Insulin-Incretin Mimetic Combinations SOLIQUA 100/33

XULTOPHY 100/3.6

Antidiabetics - Meglitinide Analogues NATEGLINIDE PRANDIN

REPAGLINIDE

STARLIX

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Illinois Medicaid

Antidiabetics - Meglitinide-Biguanide Combinations REPAGLINIDE/METFORMIN HYDROCHLORIDE

Antidiabetics - SGLT2 Inhibitor - DPP-4 Inhibitor

Combinations

GLYXAMBI

QTERN

STEGLUJAN

Antidiabetics - Sodium-Glucose Co-Transporter 2

(SGLT2) Inhibitors

INVOKANA FARXIGA

JARDIANCE STEGLATRO

Antidiabetics - Sodium-Glucose Co-Transporter 2

Inhibitor-Biguanide Comb

INVOKAMET

INVOKAMET XR

SEGLUROMET

SYNJARDY

SYNJARDY XR

XIGDUO XR

Antidiabetics - Sulfonylurea-Biguanide Combinations GLYBURIDE/METFORMIN HCL GLIPIZIDE/METFORMIN HCL

GLUCOVANCE

Antidiabetics - Sulfonylurea-Thiazolidinedione

Combinations

DUETACT

PIOGLITAZONE HCL-GLIMEPIRIDE

Antidiabetics - Sulfonylureas CHLORPROPAMIDE AMARYL

GLIMEPIRIDE GLUCOTROL

GLIPIZIDE GLUCOTROL XL

GLIPIZIDE ER GLYNASE

GLIPIZIDE XL

GLYBURIDE

GLYBURIDE MICRONIZED

TOLAZAMIDE

TOLBUTAMIDE

Antidiabetics - Thiazolidinedione-Biguanide

Combinations

ACTOPLUS MET

ACTOPLUS MET XR

PIOGLITAZONE HCL/METFORMIN HCL

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Antidiabetics - Thiazolidinediones AVANDIA ACTOS

PIOGLITAZONE HCL

Antidotes And Specific Antagonists - Opioid Antagonists NALOXONE HCL

NALTREXONE HCL

NARCAN

VIVITROL

Antiemetic Combinations AKYNZEO

DICLEGIS

Antiemetics - 5-HT3 Receptor Antagonists ONDANSETRON HCL ANZEMET

ONDANSETRON ODT GRANISETRON HCL

SANCUSO

ZOFRAN

ZOFRAN ODT

ZUPLENZ

Antiemetics - Miscellaneous CESAMET

DRONABINOL

MARINOL

SYNDROS

Antiemetics - Substance P/Neurokinin 1 (NK1) Receptor

Antagonists

EMEND CAP 125MG APREPITANT

EMEND CAP 40MG CINVANTI

EMEND CAP 80MG EMEND SOL 150MG

EMEND TRIPACK EMEND SUS 125MG

VARUBI

Antipsychotics - Misc.* LATUDA EQUETRO

ZIPRASIDONE HCL GEODON

NUPLAZID

VRAYLAR

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Antipsychotics/Antimanic Agents - Benzisoxazoles* RISPERIDONE INVEGA SUSTENNA FANAPT

INVEGA TRINZA FANAPT TITRATION PACK

INVEGA

PALIPERIDONE ER

RISPERDAL

RISPERDAL CONSTA

RISPERDAL M-TAB

RISPERIDONE M-TAB

RISPERIDONE ODT

Antipsychotics/Antimanic Agents - Dibenzo-oxepino

Pyrroles*

SAPHRIS

Antipsychotics/Antimanic Agents - Dibenzodiazepines* CLOZAPINE TAB 100MG CLOZAPINE TAB 200MG

CLOZAPINE TAB 25MG CLOZAPINE ODT

CLOZAPINE TAB 50MG CLOZARIL

FAZACLO

VERSACLOZ

Antipsychotics/Antimanic Agents - Dibenzothiazepines* QUETIAPINE FUMARATE QUETIAPINE FUMARATE ER

SEROQUEL

SEROQUEL XR

Antipsychotics/Antimanic Agents - Dibenzoxazepines* LOXAPINE ADASUVE

LOXAPINE SUCCINATE

Antipsychotics/Antimanic Agents - Quinolinone

Derivatives*

ARIPIPRAZOLE TAB 10MG ABILIFY MAINTENA ABILIFY

ARIPIPRAZOLE TAB 15MG ARISTADA ARIPIPRAZOLE ODT

ARIPIPRAZOLE TAB 20MG ARIPIPRAZOLE SOL 1MG/ML

ARIPIPRAZOLE TAB 2MG REXULTI

ARIPIPRAZOLE TAB 30MG

ARIPIPRAZOLE TAB 5MG

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Antipsychotics/Antimanic Agents -

Thienbenzodiazepines*

OLANZAPINE TAB 10MG OLANZAPINE INJ 10MG

OLANZAPINE TAB 15MG OLANZAPINE ODT

OLANZAPINE TAB 2.5MG ZYPREXA

OLANZAPINE TAB 20MG ZYPREXA RELPREVV

OLANZAPINE TAB 5MG ZYPREXA ZYDIS

OLANZAPINE TAB 7.5MG

Antiretroviral Combinations ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE BIKTARVY

ABACAVIR/LAMIVUDINE COMBIVIR

ATRIPLA COMPLERA

DESCOVY EPZICOM

GENVOYA EVOTAZ

KALETRA TAB 100-25MG JULUCA

KALETRA TAB 200-50MG KALETRA SOL

LAMIVUDINE/ZIDOVUDINE ODEFSEY

LOPINAVIR/RITONAVIR PREZCOBIX

TRUVADA STRIBILD

TRIUMEQ

TRIZIVIR

Antiretrovirals - CCR5 Antagonists (Entry Inhibitor) SELZENTRY

Antiretrovirals - Fusion Inhibitors FUZEON

Antiretrovirals - Integrase Inhibitors ISENTRESS

ISENTRESS HD

TIVICAY

Antiretrovirals - Protease Inhibitors APTIVUS

ATAZANAVIR

ATAZANAVIR SULFATE

CRIXIVAN

FOSAMPRENAVIR CALCIUM

INVIRASE

LEXIVA

NORVIR

PREZISTA

REYATAZ

VIRACEPT

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Antiretrovirals - RTI-Non-Nucleoside Analogues EDURANT VIRAMUNE TAB 200MG

EFAVIRENZ VIRAMUNE XR

INTELENCE

NEVIRAPINE

NEVIRAPINE ER

RESCRIPTOR

SUSTIVA

VIRAMUNE SUS 50MG/5ML (Eff 3/2/18)

Antiretrovirals - RTI-Nucleoside Analogues-Purines ABACAVIR VIDEX EC

DIDANOSINE ZIAGEN TAB 300MG

VIDEXPEDIATRIC

ZIAGEN SOL 20MG/ML

Antiretrovirals - RTI-Nucleoside Analogues-Pyrimidines EMTRIVA EPIVIR

LAMIVUDINE

Antiretrovirals - RTI-Nucleoside Analogues-Thymidines STAVUDINE RETROVIR

ZIDOVUDINE ZERIT

Antiretrovirals - RTI-Nucleotide Analogues TENOFOVIR DISOPROXIL FUMARATE

VIREAD

Antiretrovirals Adjuvants TYBOST

Beta Blockers - Non-Selective HEMANGEOL

Cardiovascular Agents - Misc. - Nitrate & Vasodilator

Combinations

BIDIL

Cardiovascular Agents - Misc. - Prostaglandin

Vasodilators

EPOPROSTENOL SODIUM ORENITRAM

FLOLAN REMODULIN

TYVASO

TYVASO REFILL

TYVASO STARTER

VELETRI

VENTAVIS

Cardiovascular Agents - Misc. - Pulm Hyperten-Soluble

Guanylate Cyclase Stimulator (sGC)

ADEMPAS

Cardiovascular Agents - Misc. - Pulmonary Hypertension

- Endothelin Receptor Antagonists

LETAIRIS OPSUMIT

TRACLEER

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Illinois Medicaid


- Phosphodiesterase Inhibitors

ADCIRCA

REVATIO

SILDENAFIL

SILDENAFIL CITRATE


- Prostacyclin Receptor Agonist

UPTRAVI

Dermatologicals - Phosphodiesterase 4 (PDE4)

Inhibitors - Topical

EUCRISA

Dermatologicals - Scabicide Combinations GNP LICE SOLUTION KIT

GNP LICE TREATMENT

HM LICE KILLING MAXIMUM STRENGTH

LICE KILLING MAXIMUM STRENGTH

LICE KILLING SHAMPOO

SM LICE KILLING MAXIMUM STRENGTH

SM LICE SOLUTION KIT

Dermatologicals - Scabicides & Pediculicides EURAX ELIMITE

GNP LICE TREATMENT LINDANE

HM LICE TREATMENT MALATHION

LICE TREATMENT OVIDE

NATROBA SPINOSAD

PERMETHRIN

SKLICE

Digestive Enzymes CREON PANCREAZE

ZENPEP PERTZYE

VIOKACE

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Illinois Medicaid

Glucose Monitoring Supplies - Kits ONETOUCH KIT ULT MINI All Other Products

ONETOUCH KIT ULTRA 2

ONETOUCH KIT VERIO FL

ONETOUCH KIT VERIO IQ

ONETOUCH VERIO

Glucose Monitoring Supplies - Test Strips ONETOUCH TES VERIO All Other Products

ONETOUCH ULTRA BLUE

Growth Hormones GENOTROPIN HUMATROPE

GENOTROPIN MINIQUICK HUMATROPE COMBO PACK

NORDITROPIN FLEXPRO

NUTROPIN AQ NUSPIN 10



OMNITROPE

SAIZEN

SAIZEN CLICK.EASY

SAIZENPREP RECONSTITUTIONKIT

SEROSTIM

ZOMACTON

ZORBTIVE

Hematopoietic Agents - Erythropoiesis-Stimulating

Agents (ESAs)

ARANESP ALBUMIN FREE EPOGEN

PROCRIT MIRCERA

Hematopoietic Agents - Granulocyte Colony-Stimulating

Factors (G-CSF)

GRANIX NEULASTA

NEUPOGEN NEULASTA ONPRO KIT

ZARXIO

Hepatitis C Agent - Combinations EPCLUSA HARVONI

MAVYRET TECHNIVIE

VIEKIRA PAK

VIEKIRA XR

VOSEVI

ZEPATIER

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Illinois Medicaid

Hepatitis C Agents MODERIBA TAB 200MG PEGINTRON DAKLINZA

RIBASPHERE CAP 200MG MODERIBA TAB 1000/DAY

RIBASPHERE TAB 200MG MODERIBA TAB 600/DAY

RIBAVIRIN MODERIBA 1200 DOSE PACK

MODERIBA 800 DOSE PACK

OLYSIO

PEGASYS

PEGASYS PROCLICK

REBETOL

RIBASPHERE TAB 400MG

RIBASPHERE TAB 600MG

RIBASPHERE RIBAPAK

SOVALDI

Inflammatory Bowel Agents BALSALAZIDE DISODIUM APRISO

CANASA ASACOL HD

MESALAMINE ENE 4GM AZULFIDINE

PENTASA AZULFIDINE EN-TABS

SFROWASA COLAZAL

SULFASALAZINE DELZICOL

DIPENTUM

GIAZO

LIALDA

MESALAMINE KIT 4GM

MESALAMINE DR

ROWASA

Inflammatory Bowel Agents - Integrin Receptor

Antagonists

ENTYVIO

Inflammatory Bowel Agents - Interleukin Antagonists STELARA

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Illinois Medicaid

Inflammatory Bowel Agents - Tumor Necrosis Factor

Alpha Blockers

CIMZIA INFLECTRA

CIMZIA STARTER KIT REMICADE

RENFLEXIS

Multiple Sclerosis Agents COPAXONE INJ 20MG/ML COPAXONE INJ 40MG/ML

GLATIRAMER ACETATE

GLATOPA

Multiple Sclerosis Agents - - Pyrimidine Synthesis

Inhibitors

AUBAGIO

Multiple Sclerosis Agents - Interferons BETASERON AVONEX

REBIF AVONEX PEN

REBIF REBIDOSE EXTAVIA

REBIF REBIDOSE TITRATIONPACK PLEGRIDY

REBIF TITRATION PACK PLEGRIDY STARTER PACK

Multiple Sclerosis Agents - Monoclonal Antibodies LEMTRADA

OCREVUS

TYSABRI

ZINBRYTA

Multiple Sclerosis Agents - Nrf2 Pathway Activators TECFIDERA

TECFIDERA STARTER PACK

Multiple Sclerosis Agents - Potassium Channel Blockers AMPYRA

Multiple Sclerosis Agents - Sphingosine 1-Phosphate

(S1P) Receptor Modulators

GILENYA

Ophthalmic Antiallergic AZELASTINE HCL ALOCRIL

CROMOLYN SODIUM ALOMIDE

PAZEO BEPREVE

ELESTAT

EMADINE

EPINASTINE HCL

LASTACAFT

OLOPATADINE HCL

OLOPATADINE HYDROCHLORIDE

PATADAY

PATANOL

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Illinois Medicaid

Otic Steroid-Anti-infective Combinations CIPRODEX CIPRO HC

NEOMYCIN/POLYMYXIN/HC COLY-MYCIN S

NEOMYCIN/POLYMYXIN/HYDROCORTISONE OTOVEL

Phosphate Binder Agents CALCIUM ACETATE AURYXIA

FOSRENOL PHOSLYRA

LANTHANUM CARBONATE RENVELA

RENAGEL SEVELAMER CARBONATE

VELPHORO

Progestins MAKENA

Smoking Deterrents BUPROPION HCL SR

CHANTIX

CHANTIX CONTINUING MONTHPAK

CHANTIX STARTING MONTH PAK

GNP NICOTINE MINI LOZENGE

GNP NICOTINE POLACRILEX

GNP NICOTINE POLACRILEX MINI

GNP NICOTINE TRANSDERMALSYSTEM

GOODSENSE NICOTINE

GOODSENSE NICOTINE GUM

GOODSENSE NICOTINE POLACRILEX

HM NICOTINE POLACRILEX

HM NICOTINE TRANSDERMAL SYSTEM

HM NICOTINE TRANSDERMAL SYSTEM STEP 3

HM NICOTINE TRANSDERMALSYSTEM

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Illinois Medicaid

NICODERM CQ

NICORELIEF

NICORETTE

NICORETTE MINI

NICORETTE STARTER KIT

NICOTINE POLACRILEX

NICOTINE TRANSDERMAL SYSTEM

NICOTINE TRANSDERMAL SYSTEM STEP 1



NICOTROL INHALER

NICOTROL NS

SM NICOTINE

SM NICOTINE POLACRILEX

SM NICOTINE TRANSDERMAL SYSTEM

ZYBAN

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